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_ SAN- JOAQUIN LOCAL HEALTk DISTRICT <br /> r,OF. O-FICE USE: /C1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 30V, APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?S�,s_Z_ r� <br /> THIS PERMIT EXPIRES .l YEAR FROM DATE ISSUED Date Issued �r- <br /> (Complete In Triplicate) <br /> Application is hereby fTnade to the San Joaquin Local Health District for a permit to construct � <br /> acrd/or install the worherein described. ' This application is made in compliance with San Joaqulx <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION ©e-0 CENSUS TRACT <br /> �j <br /> Owner's Name Phone _14 -- 7 7 7 iv0?=y <br /> Address . 0, `s`f 7 City <br /> iE <br /> Contractor's-Name License # Phone' 66-[1bg6 <br /> E <br /> Ij <br /> TYPE OF WORK (Check) :. NEW WELL 97 DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION X7PUMP REPAIR / J PUMP REPLACEMENT /_7— <br /> Other /7 €� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool' Dia. of Well Excavation ` <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public! Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout S al <br /> ' Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done i <br /> t i <br /> PUMP TtEPAIR: / / State Work Done <br /> 3 ' <br /> i DF-,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure € <br /> P € <br /> 3 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> p and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS- <br /> after completion of my work on a new well, I will furnish the San Joaquin Local. Health District:;a <br /> WELL DRILLERS REPORT ' .the well and notify them before putting the well. in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED �' TITLE ' 1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> y <br /> i FOR DEPARTMENT USE ONLY <br /> e PHASE I <br /> APPLICATION ACCEPTED BY <br /> l DATt" M <br /> ADDITIONAL COMMENTS: € <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION '€ <br /> INSPECTION BY €M DATE _ INSPECTION BY 1-19-7k - DATE <br /> iM C/ <br /> CALL FOR A GROUT INSPECTION PRIOR ,TO GROUTING AND ,FINAL INSPECTION. <br /> E H 1426 I 5/731M <br />